Heart transplants

Most people enjoy an excellent quality of life after a heart transplant, says Dr Jayan Parameshwar, consultant cardiologist at Papworth Hospital's transplant unit.

If you have dilated cardiomyopathy, your cardiologist is likely to treat you with several drugs known to improve symptom control and prognosis. 

Some of you will also benefit from the insertion of a biventricular pacemaker.  If your quality of life is poor despite such therapy, or if there is evidence that other organs (particularly the kidneys) are being affected by the failing heart, a heart transplant should be considered. 

If you are referred, you are likely to undergo an assessment at the transplant centre. It will usually include two to three days in hospital. You will have investigations to establish the severity of your heart failure, and to exclude conditions that would adversely affect the outcome of a potential transplant. 

Transplantation

Once accepted for transplantation, you face a waiting period that varies greatly depending on your blood group and size. 

Because of a shortage of donor organs, inevitably everyone who could potentially benefit from a transplant will not receive one.  Some patients improve significantly and may be able to come off the transplant list and continue on medication.

When the transplant centre knows there may be a suitable heart available, you will be contacted and arrangements made to take you to hospital.  There may be “false alarms” when the donor organ, on further investigation, is found to be unsuitable (usually because of poor function).  About ten per cent of donor organs will not work satisfactorily in the recipient after implantation.  This is the main cause of mortality in the peri-operative period.

Surgery 

The duration of surgery varies depending on what procedures the recipient has had in the past, but averages about four hours. You can expect to be awake in a day and to spend a day or two in the intensive care unit. 

The operation involves removing most of your own heart; a small cuff of the upper chambers may be left to suture the new heart onto.   

You will spend an average of three weeks in hospital and will be able to learn about your immunosuppressive drug combination, and how you can monitor yourself at home for complications.  You will receive physiotherapy, and be given advice on diet and lifestyle changes.  Most people take several months to reach full fitness.

Recovery

Depending on your occupation you may return to work three to six months after a heart transplant.  Most people enjoy an excellent quality of life and rarely need admission to hospital other than for planned investigations.

During the first year you will need frequent hospital visits for tests including biopsies of your heart to look for evidence of rejection.  A biopsy is an outpatient procedure (under local anaesthetic) and takes 20 to 30 minutes. 

Rejection, damage to your heart caused by the immune system, is almost always treatable by adjusting the dose of immunosuppressive medication.   Blood tests will check blood levels of medication and look for side- effects of therapy.

Most patients accepted on to a transplant waiting list have an expected survival of 50 per cent or less over the following two years.  Survival after a heart transplant is 80 per cent, 70 per cent and 55 per cent at one, five, and ten years respectively. 

Immunosuppression

The most important long-term problems fall into two groups:
(a) immunosuppression side-effects
(b) immune damage to the heart that occurs in spite of drug therapy

There are two important side effects of immunosuppression: an increased risk of cancer and kidney dysfunction. Fifteen to  20 per cent of patients will develop a malignancy after a heart transplant; about half are skin cancers, superficial and relatively easily treated.  Lymph gland tumours affect up to five per cent of patients and often require chemotherapy.  Other tumours are less common.

Kidney dysfunction is caused by one class of medication used to suppress the immune system.  While some abnormality in kidney function is detectable on testing in most patients, a minority (about six per cent in the first ten years) develop kidney failure requiring dialysis.  Newer drugs offer the promise of equal efficacy without affecting the kidney.

Despite immunosuppression, the immune system will eventually affect the donor heart.  This usually manifests as a form of coronary artery disease (obstruction to blood flow in the donor heart).  It is uncommon in the first few years but is the most important problem after ten years.  It is often widespread and rarely amenable to treatment by surgery. 

While a second transplant is possible, it is an option that is available to very few.

In summary, for selected patients with severe heart failure, heart transplantation offers a marked improvement in prognosis and quality of life.  The shortage of donor organs is the main factor limiting access to this form of treatment.